Cancers preventive practice and the determinants in Amhara regional state, Northwest Ethiopia

Background Cancer is the leading cause of morbidity and mortality globally. In Ethiopia, 5.8% of deaths are attributed to cancer. Therefore, this study aimed to examine the cancers preventive practice and associated factors in North West Ethiopia, 2019. Methods A community-based cross-sectional study was conducted among Bahir Dar city residents. A multistage sampling technique was used to select 845 study participants. Data were collected through a validated interviewer administered questionnaire. The questionnaire was adapted from the American cancer association cancer prevention toolkit. Descriptive statistics were computed and presented in charts and texts. The model fitness was checked using Hosmer and Lemeshow goodness of fit (P > 0.05). Bivariable and multivariable logistic regressions were used to identify factors associated with cancer preventive practice. A p-value < 0.2 at bivariate analysis was candidate variables for multivariable logistic regression analysis. Finally, p-value of < 0.05 was considered as a statistically significant predictor for cancer preventive practice at the 95% confidence interval. Result A total of 845 study participants took part in the study. Nearly 63% of the respondents were females. About 28% (95%CI: 24, 30) of the study participants had good preventive practice. Age ≥ 45 years (AOR = 0.31; 95%CI: 0.15, 0.62), female (AOR = 0.50, 95%CI: 0.35, 0.71) family member with cancer (AOR = 1.68, 95%CI: 1.07, 2.62) and had good knowledge (AOR = 1.66, 95%CI: 1.14, 2.42) were the identified determinants of cancer preventive practices. Conclusion This study revealed that the level of cancer preventive practices was low. Family member with cancer, knowledge about cancer, older age, and being female were significantly associated with cancer preventive practices. This finding underscores the importance of interventions to enhance cancer preventive practices.


Methods
A community-based cross-sectional study was conducted among Bahir Dar city residents. A multistage sampling technique was used to select 845 study participants. Data were collected through a validated interviewer administered questionnaire. The questionnaire was adapted from the American cancer association cancer prevention toolkit. Descriptive statistics were computed and presented in charts and texts. The model fitness was checked using Hosmer and Lemeshow goodness of fit (P > 0.05). Bivariable and multivariable logistic regressions were used to identify factors associated with cancer preventive practice. A pvalue < 0.2 at bivariate analysis was candidate variables for multivariable logistic regression analysis. Finally, p-value of < 0.05 was considered as a statistically significant predictor for cancer preventive practice at the 95% confidence interval.

Conclusion
This study revealed that the level of cancer preventive practices was low. Family member with cancer, knowledge about cancer, older age, and being female were significantly associated with cancer preventive practices. This finding underscores the importance of interventions to enhance cancer preventive practices.

Background
The World Health Organization (WHO) reported that nearly 18.1 million new cases and 9.6 million deaths had occurred worldwide due to cancer [1]. In low-and middle-income countries, approximately 70% of deaths are attributed to cancer [1,2]. In Africa, cancer is an emerging public health issue with estimates of 715, 000 new cases and 542,000 deaths in 2008 [1][2][3].
The fast-growing, aging population and the surge in the prevalence of the risk factors, such as tobacco use, obesity, alcohol use, unhealthy diet, physical inactivity, and the changes in reproductive health patterns related to urbanization, have been increasing the cancer burden in Ethiopia since recent years. Recognizing this threat, the Ethiopian government has launched a national cancer control plan in 2015. The plan set ambitious objectives to expand a range of preventive interventions, screening tests for early detection, and diagnosis and treatment. It aims to increase cancer awareness of general population by 50%, to reduce the prevalence of tobacco smoking by 30%, overweight and obesity by 5%, prevalence of insufficient physical activity by 10%, prevalence of harmful use of alcohol by 5%, to increase in mean population intake of fruits and vegetables at least twice per week by 15%, and to achieve 80% coverage of vaccine against HPV for girls aged 9 to 13, in 2020 [12]. The Ethiopian cancer control policy urgently requires a clarification of the discrepancies which now exist between ideal levels of public awareness and preventive practice about cancer risk factors and current reality on preventive practices as well [14]. To contribute to the urgent need for the policy, this study aimed to determine the cancer preventive practice level and the determinants among Bahir Dar city residents, northwest Ethiopia.

Study Design, period and setting
A community-based cross-sectional study was employed among adults (18 years and above) of Bahir Dar city residents from May to June 2019. The study setting Bahir Dar city is the capital of Amhara National Regional State which has nine sub-cities. The total population of the city is estimated to be 274,459. Of these, 136,730 were females [15].

Population and sample
The sample size was determined using a single population proportion formula with the assumptions of cancer preventive practice (50%), 5% margin of error, 10% non-response rate, and a design effect of 2 yielded a final sample size of 845. A multistage sampling technique was used to recruit the study participants from nine subcities.
Then, proportional to size allocation was applied, and a systematic sampling technique was used. Accordingly, 201 (Hidar 11), 190 (Fasilo), 129 (Tana), and 325 (Belay Zeleke) participants were selected from the four sub-cities, respectively. Whenever more than one eligible family member was in a household, only one individual was chosen for study using a lottery method.

Data collection procedure
A pretested, interviewer-administered structured Amharic questionnaire was used to determine cancer-preventive practice. The questionnaire was adapted from the American cancer association tool kit and was slightly modified and translated to the Amharic language. The questionnaire had three components; socio-demographic, knowledge about cancer, and cancer preventive-practice-related characteristics. All enumerators secured written consent from participants before collecting the data. To maintain the quality of the data and to assure that all team members were able to administer the questionnaires uniformly, one day of rigorous training was provided to four nurses with bachelor's degrees (data collectors) and to two supervisors with master's degrees.
Enumerators and the supervisors carried out role-plays and had field pre-test activities. On the afternoon of every data collection day, the supervisor assessed each questionnaire and gave feedback to the enumerators. The internal consistency (Cronbach alpha) level of the pretest of cancer preventive practice was 0.86.

Operational definitions
Cancer preventive practice. Those respondents who scored mean and above of the cancer-preventive practice assessing questions correctly were considered as having good practice. Otherwise, they were considered as having poor practices.
Knowledge about cancer. Those respondents who scored mean and above of the knowledge assessing questions correctly were considered as having good knowledge about cancer. Otherwise, they were considered as having poor knowledge.
A unit of alcohol. Is one small measure of spirits, half a pint of lager (3-4% strength), or half a small glass (175ml) of wine (12% strength).

Data processing and analysis
Data entry, cleaning, and coding were performed using Epi Data version 4.12 and analyzed using SPSS version 23.0 software. Descriptive statistics were computed. A logistic regression model was used to identify the association between explanatory and outcome variables. Multicollinearity was checked for the data. The model fitness was checked using Hosmer and Lemeshow goodness of fit (P> 0.05). Predictor variables having p-values < 0.20 were taken into a multivariable logistic regression analysis to see associations between dependent and independent variables. P-values less than 0.05 were taken as the identified predictors of cancer preventive practices.

Ethical Consideration and consent to participate
Ethical approval was obtained from GAMBY Medical and Business College, Research, and health institute. The support letter was obtained from the Bahir Dar city administration. The objective of the study was clarified to the study participants, and they were also notified that they have the right to opt-out of the study at any point in the interview. Then, the written consent was secured from the respondents. The written consent and the data collection tools were documented and kept confidential in a secure place.

Socio-demographic characteristics
A total of 845 study participants took part with a response rate of 98%. The median (±IQR) age of the respondents was 27 (22.35) years. Sixty-three percent of the respondents were males. And about forty-six percent of the respondents were married. Nearly one-third of the respondents had attended secondary education. Furthermore, 24.6% of the participants were privately employed, and nearly one-third (32%) of them were living in privately owned houses, respectively ( Table 1).

Knowledge about cancer risk factors
Regarding knowledge about risk factors, exposure to cigarette smoking (74.9%), infection with human papillomavirus (HPV) (53.1%), and chronic infection with Hepatitis B or C (49.2%) were the most enlisted risk factors. Only one hundred seventy-one (20.2%) of participants had good knowledge about cancer risk factors ( Table 3).

The level of cancer preventive practices
From cancer prevention practices, about 46.5% of participants did slight physical exercises, 51.7% usually sleep 5-8 hours per day, 88% did not smoke cigarettes, and 45.3% never drink alcohol. About 79% of males and females had a routine screening in the past two years. Nearly 49% of males and 44% of females underwent a physical examination for symptoms in the last two years ( Table 4).

Factors associated with cancer preventive practices
In the univariate logistic regression analysis, age, sex, occupation, marital status, education, knowledge about cancer risks, and family member with cancer were the factors associated with cancer preventive practice at a 20% level of significance. In the multivariable logistic regression analysis, age, sex, knowledge about cancer risks, and family member with cancer were predictors of cancer preventive practice at a p-value of less than < 0.05. Thus, for those study participants whose age was above 45 years, the odds of cancer preventive practice were 69% (AOR = 0.31; 95%CI: 0.15, 0.62) lower compared to younger respondents. Similarly, females had a 50% (AOR = 0.50; 95%CI: 0.35, 0.71) of lower chance of cancer preventive practice compared to males. Conversely, for those study participants who had a family member with cancer, the odds of cancer preventive practice was 1.66 (AOR = 1.68; 95% CI: 1.07, 2.62) times higher compared to those who had not. Likewise, for those participants who had good knowledge about cancer risks, the odds of cancer preventive practice were 1.66 (AOR = 1.66; 95%CI: 1.14, 2.42) times higher compared to those who had poor knowledge about cancer risks ( Table 5).

Discussion
In Ethiopia, awareness creation and behavioral change communication are the pivots for the early detection, prevention, and control strategies of cancer [16]. The current study determined the level of cancer preventive practices. This study revealed that 27.5% of the participants had good preventive practices. In this study, nearly half of the respondents were aware of the warning symptoms of cancer. Of which, unexplained lump/swelling, not healing sore, unexplained bleeding, and persistent unexplained pain were the most commonly mentioned warning symptoms.
Eating fatty and processed meat, being overweight, not eating fruits and vegetables, and physical inactivity were fewer recognized risk factors of cancer by the respondents. The current findings were supported by other studies [17][18][19].
In addition, this study revealed only 20.2% of the respondents knew about cancer prevention. Physical exercise, adequate sleep time, and self-breast examination were the commonly mentioned cancer preventive practices by the respondents. Thus, huge tasks are needed to improve the cancer awareness and preventive practices of the community through health education and behavioral change communication. The current study also identified the factors affecting cancer-preventive practice in Bahir Dar city. Older age, female sex, family member with cancer, and knowledge about cancer risks were determinants of cancer preventive practices.
For older ages (> 45 years), the odds of cancer preventive practice were 69% lower compared with younger ages. This finding was against the study done in India [20]. This discrepancy could be differences in the study population, period, and socio-cultural characteristics. The other possible explanation could be the current study was done in both sexes and on all cancer preventive practices. However, the Indian study was done on cervical-cancer related issues among the female population.
Likewise, for those female respondents, the odds of cancer preventive practice were 50% lower compared with male respondents. This finding was in line with the study done in high, middle, and low-income countries [2]. This finding could be justified majority of the respondents were females, and nearly 20% of them were not attended formal education. This could lead the respondents to less possibility of utilizing various social media, including internet access. In the meantime, females are busy with home-based tasks and might not give attention to cancer preventive practices. Hence, programs should target both females and males. Because if males are aware of females' challenges, may encourage females to seek cancer prevention services.
Family member with cancer was the other determinant factor significantly associated with cancer preventive practices. For those participants whose family members had cancer, the odds of cancer preventive practices were 1.7 times higher compared with those who had not. This finding was in agreement with the study done in Iran and two studies in Saudi Arabia [5,10,11]. The possible justification for this could be some forms of cancer are a family or hereditary transfer [21], and the other family members would be worried about the complications of cancer suffering family member. And they have the likelihood of accessing information about the risk factors and preventive modalities of cancer, which would help them to implement cancer-preventive actions.
Moreover, this study also identified those participants who had good knowledge about cancer risk factors were 1.7 times higher compared with those who had poor knowledge. This finding is in line with the study findings of Iran, Ethiopia, Saudi, South Africa, and India, respectively [5,8,10,11,19,20]. Having better knowledge and understanding of cancer could help to implement cancer-preventive practices at the household level.
This study implicated that public health practitioners, policymakers, and other concerned stakeholders should have to strengthen cancer-related health education and behavioral change communications in the community to enhance the awareness of cancer risk factors and to support them implement the cancer-preventive practice.

Strength of the study
Being a larger sample-sized, community-based, and both sexes included study make the result inferable to the community of Bahir Dar city.

Limitations of the study
The cross-sectional nature (chicken-egg dilemma) of the study and recall and information bias was the weakness of this study. The study didn't identify the other possible barriers (like age restrictions for screening/examination services, cost of fruits and vegetables) to uptake cancer preventive practices.

Conclusion
Knowledge about cancer risks and good preventive practices was low. Family member with cancer and knowledge about cancer risks had higher odds of cancer preventive practices. Conversely, older age and female sex had lower odds of cancer preventive practices. This finding underscores the important interventions to enhance cancer awareness and preventive practices.